Case Report J. V e s a , O . B i e l s a , O . A r a n g o , C. L l a d 6 , A . G e l a b e r t

Massive Renal Infarction Due to Mucormycosis in an AIDS Patient Summary: Isolated renal infection by Mucor spp. occurs very rarely, even in the immunocompromised host. The mortality of the different forms of mucormycosis reaches 75-100% in most series. Infection of the kidney is usually diagnosed post-mortem. Thus, when renal infection is recognized, aggressive treatment including surgery and amphotericin B is required. We present a case in which a massive left renal infarction was the unique manifestation of mucormycosis in an AIDS patient. Administration of amphotericin B and left nephrectomy were necessary to achieve satisfactory outcome.

Zusammenfassung: Massiver Niereninfarkt durch Mucormykose bei einem AIDS-Patienten. Isolierte Mucor-Infektionen der Niere sind auch bei abwehrgeschw~ichten Patienten eine Seltenheit. In den meisten Serien liegt die Letalit~it der verschiedenen Formen der Mucormykose bei 75 bis 100%. Meist wird die Infektion der Niere erst autoptisch diagnostiziert. Die Mucormykose der Niere erfordert eine aggressive Therapie mit Operation und Amphotericin B-Behandlung. Wit stellen einen AIDS-Kranken vor, bei dem sich die Mucormykose nur an der Niere manifestierte. Dutch operative Entfernung der linken Niere und Behandlung mit Amphotericin B konnte ein zufriedenstellendes Ergebnis erzielt werden.

Case Report A 26-year-old man with a five-year history of intravenous drug use (heroin) was admitted to our hospital with a one-week history of continuous left loin pain, fever, dysuria, frequent urination and tenesmus. On physical examination slight signs of cellulitis were noted on the painful area. Urine culture was negative. Chest x-ray suggested active pulmonary tuberculosis, and Ziehl-Neelsen stains of sputum samples were positive for acid fast bacilli. Mycobacteriurn tuberculosis was grown on L6wenstein medium. Serological tests for human immunodeficiency virus (HIV) were also positive. Ultrasound examination showed a normal right kidney and areas of mixed echogenicity in the left kidney, which was enlarged. Intravenous urography revealed a non-functioning left kidney, with the right kidney and the rest of the urinary tract being normal. Computed tomography (CT) showed a mixed hypo- and hyperdense pattern in the entire left kidney as well as changes in the density of the perirenal fat suggestive of severe inflammation (Figure 1). Initially, a renal abscess was suspected. Empiric therapy with cloxacillin and gentamicin was started. A percutaneous translumbar puncture was performed in an attempt to drain the suspected renal abscess, but only a small amount of whitish doughy material was obtained; Gram and Ziehl-Neelsen stains and standard cultures were negative. The patient failed to improve clinically, as evidenced by persistent high temperature and severe leukopenia (1,200-2,000/mm3). A surgical approach was therefore selected, and a left nephrectomy was performed (Figure 2). On gross examination the kidney presented as a

Introduction Fungal infections of the urinary tract are uncommon [1], occurring usually in immunocompromised persons such as diabetics, transplant patients and those receiving cytotoxic drugs for neoplasic disease, as well as in persons living in unsanitary conditions who carry a permanent Foley catheter [2]. Intravenous drug users must also be considered an important risk group, as they usually have immunologic disorders. In addition, the self-injection of the drug is done under unhygienic conditions. Mucormycosis is an aggressive, virulent infection caused by fungi classified within the family Mucoraceae. As a rule, the prognosis of mucormycosis is poor. Isolated renal infection is an unusual manifestation of mucormycosis, and thus only a few cases have been reported [3]. We report a case of isolated renal mucormycosis in an intravenous drug user who developed an acquired immunodeficiency syndrome (AIDS).

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Figure 1: Computed tomography scan showing mixed hypoand hyperdense pattern in the left kidney and changes in the density of the perirenal fat. Received: 12 February 1992/Accepted: 16 March 1992 Dr. Z Vesa,Dr. O. Bielsa,Prof. Dr. O. Arango, Dr. C, Llad6, Prof. Dr.A. Gelabert, Urology Service, Hospital del Mar, Passeig Marftim 25-29, E-08003 Barcelona, Spain. Correspondence and reprint requests to: Dr. J. Vesa,Jacinto Verdaguer No. 30 5° 2~esc. B, E-I760 Figueres (Girona), Spain.

Infection 20 (1992) No. 4 © MMV Medizin Verlag GmbH Mfinchen, Miinchen 1992

J. Vesa et al.: Renal Infarction Due to Mucormycosis

Figure 2: Perioperative view showing the kidney as a soft and necrotic mass with irregular outer surface.

Figure 4a: Renal parenchyma. Glomerulus surrounded by necrotic tissue and massive invasion by fungal hyphae. (H-E x40).

Figure 3: Surgical specimen. The entire kidney is occupied by fungi.

Figure 4b: Close-up showing the large, broad, aseptate hyphae characteristic of Mucor spp. (H-E x400).

whitish soft mass with irregular surface and necrotic outward appearance; several lesions suggesting cortical abscesses were noted in the lower pole (Figure 3). The same characteristics were found inside the kidney. Renal mucormycosis was diagnosed by microscopic examination using haematoxylin-eosin, Groccot and PAS stains. Mucor spp. were identified by large, broad, aseptate fungal hyphae with haphazard irregular branching and haematoxyphilia (Figures 4a, 4b). The patient had an uneventful postoperative recovery. Cerebral and pulmonary mucormycoses were ruled out, and antifungal treatment with amphotericin B was started immediately. The patient showed a progressive clinical improvement.

It is well recognized that infections due to these fungal pathogens occur in patients with underlying immunological disorders, such as diabetics with acidosis, neutropenic patients with haematologic disorders, patients with terminal carcinomatosis, organ transplant recipients, and patients undergoing chemotherapy with cytotoxic drugs [2, 4, 5, 7, 8]. Recently, several cases of focal cerebral mucormycosis have been reported in intravenous drug users, although biologic evidence of immunodeficiency was not proved; the direct inoculation of sporulated forms present in the drug itself or in the needle and syringe used has been suggested as a route of entry [9]. The disease is manifested in several different clinical patterns: rhino-orbito-cerebral (the most common), pulmonary, widely disseminated, gastrointestinal and cutaneous [2,8,10]. Isolated renal infection, as reported here, is extremely rare [1,3,11]. Usually, infection involving the renal parenchyma is of a widely disseminated form, in which mortality reaches 100% [2].

Discussion

Mucormycosis is an uncommon fungal infection caused by members of the order Mucorales, of which the most common species causing infection in humans are Rhizopus oryzae and Absidia corymbifera [4,5]. However, mucormycosis caused by certain rare species such as CunninghameUa or Rhizopus rhizopodiformis has been reported [5, 6].

Infection 20 (1992) No. 4 © MMV Medizin Verlag GmbH Miinchen, Miinchen 1992

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J. Vesa et al.: Renal Infarction Due to Mucormycosis The diagnosis depends on the demonstration of fungi in biopsy specimens. Aseptate, broad, irregular branched hyphae are characteristic of Mucor spp. These organisms have a special propensity for vascular invasion and can cause extensive cortical infarcts and medullary necrosis in the kidneys [7]. Cortical and medullary abscesses are also characteristic of renal infection [1], as was found upon gross examination of the kidney in our patient. Some authors have reported the use of the Indium 111 leukocyte scan in the diagnosis of unsuspected fungal infections in the immunocompromised host. In the cases reported, the scan facilitated the diagnosis of mucormycosis by enabling targeted biopsy of the integumentary lesions [12]. Treatment of isolated renal mucormycosis must include complete surgical excision of the infected and necrotic tissue, as well as administration of amphotericin B, 0.6 to 1 mg/kg/day up to a maximum total dose of 2 to 3 g [13]. Our patient was an intravenous drug user who had AIDS.

Because the clinical and radiologic features of this patient resembled those of renal abscess seen previously in other intravenous drug users, we initially suspected an abscess in this patient as well. Conservative treatment consisting of percutaneous drainage of the supposed purulent collection was first attempted, but only an aggressive surgical approach together with the administration of amphotericin B resulted in a satisfactory outcome. It is well known that patients with late-stage HIV infection or AIDS are at high risk for contracting infections caused by opportunistic pathogens, including some fungi. Mucor spp. must be included among the fungi that may cause rare clinical forms of mucormycosis such as focal cerebral or isolated renal infections. In our case we speculate, as have other authors [3], that the failure to locate a primary focus was due to a subclinical primary infection with haematogenous dissemination to the kidney, similar to renal tuberculosis.

References 1. Raghavan, R., Date, A., Bhaktaviziam, A.: Fungal and nocardial infections of the kidney. Histopathology 11 (1987) 9-20. 2. Hawkins, C., Armstrong, D.: Fungal infections in the immunocompromised host. Clin. Haematol. 13 (1984) 599-630. 3. Flood, H. D., O'Brien, A. M., Kelly, D. G.: Isolated renal mucormycosis. Postgrad. Med. J. 61 (1985) 175-176. 4. Berenguer, J., Solera, J., Moreno, S., Mufioz, P., Parras, F.: Mueormicosis. E1 espectro de la enfermedad en 13 pacientes. Med. Oin. (Barcelona) 94 (1990) 766-772. 5. Kolbeck, P. C., Makhoul, IL G., Boilinger, R. R., Sanfilippo, F.: Widely disseminated Cunninghamella mucormycosis in an adult renal transplant patient: case report and review of the literature. Am. J. Clin. Pathol. 83 (1985) 747-753. 6. West, B. C., Kwon-Chung, K. J., King, J. W., Grafton, W. D., Rohr, M. S.: Inguinal abscess caused by Rhizopus rhizopodiformis: successful treatment with surgery and amphotericin B. J. Clin. Microbiol. 18 (1983) 1384-1387. 7. Dei Real, O., Zamoea, J., Abud, C., Sada, E., Ponce de Le6n, S.,

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Ruiz-Palaeios, G.: Mucormicosis. Informe de 14 casos. Rev. Invest. Clin. 35 (1983) 237-240. Ferry, A. P , Abedi, S.: Diagnosis and management of rhinoorbitocerebral mucormycosis (phycomycosis). A report of 16 personally observed cases. Ophthalmology 90 (1983) 1096-1104. Stave, G. M., Heimberger, T., Kerkering, T. M.: Zygomycosis of the basal ganglia in intravenous drug users. Am. J. Med. 86 (1989) 115117. Clark, R., Greer, O. L, Carlisle, T., Carroll, B.: Cutaneous zygomycosis in a diabetic HTLV-I seropositive man. J. Am. Acad. Dermatol. 22 (1990) 956-959. Davila, R. M., Moser, S. A., Grosso, L E.: Renal mucormycosis: a case report and review of the literature. J. UroL 145 (1991) 12421244. Haseman, M. K., Blake, K., McDongall, I. R.: Indium 111 WBC scan in local and systemic fungal infections. Arch. Intern. Med. 144 (1984) 1462-1463. Clemente~ C.: Tratamiento actual de las micosis sist6micas. Med. Clin. (Barcelona) 81 (1983) 589-594.

Infection 20 (1992) No. 4 © MMV Medizin Veflag GmbH Miinchen, Miinchen 1992

Massive renal infarction due to mucormycosis in an AIDS patient.

Isolated renal infection by Mucor spp. occurs very rarely, even in the immunocompromised host. The mortality of the different forms of mucormycosis re...
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